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Pediatric HISTORY AND PHYSICAL EXAMINATION

INSTRUCTIONS FOR USE OF THE SECTION ON PEDIATRIC HISTORY AND PHYSICAL EXAM

The following outline for the Pediatric History and Physical Examination is comprehensive and detailed. In order to
assimilate the information most easily, it is suggested that you read through the whole section before examining your first
patient to get a general idea of the scope of the pediatric evaluation. Then, as you encounter patients with specific problems,
you may return to the individual sections most pertinent to these patients to absorb the information in detail. Repeat
practice with a variety of patients of different ages is crucial to the acquisition of skills in data collection. You should use
every opportunity possible to evaluate patients in order to develop a sense of normal growth and development and
appreciate the variations in patient encounter that is necessary to perform appropriate evaluation children of different ages.

OUTLINE FOR PEDIATRIC HISTORY AND PHYSICAL EXAMINATION

HISTORY
I. Presenting Complaint (Informant/Reliability of informant)
Patient's or parent's own brief account of the complaint and its duration. Use the words of the informant whenever possible.

II. Patient Profile

A good patient profile will eliminate the need for a social history. It should include information relative to the child's living
conditions, what the family unit is like, where the patient fits into this unit, background and education of parents, father's
work or lack of such, how child spends an average day (plays in house, plays outside with many friends, etc.). In the school
age child, information should be checked relative to his functioning in school, and the presence of specific learning or
behavior problems. The family's socio-economic situation should be asked about as well as medical insurance. This
paragraph is most useful for paramedical personnel as it gives them a summary of the "whole" child.

III. Present Illness

Begin with statement that includes age, sex, color and duration of illness, ex.: This is the first UMC admission for this 8
year old white male who has complained of headache for 12 hours TPA. When was the patient last entirely well? How and
when did the disturbance start? Health immediately before the illness. Progress of disease; order and date of onset of new
symptoms. Specific symptoms and physical signs that may have developed. Pertinent negative data obtained by direct
questioning. Aggravating and alleviating factors. Significant medical attention and medications given and over what
period.

In acute infections, statement of type and degree of exposure and interval since exposure.

For the well child, determine factors of significance and general condition since last visit.

IV. Past Medical History

A. Antenatal: Health of mother during pregnancy. Medical supervision, drugs, diet, infections such as rubella, etc., other
illnesses, vomiting, toxemia, other complications; Rh typing and serology, pelvimetry, medications, x-ray procedure,
maternal bleeding, mother's previous pregnancy history.

B. Natal: Duration of pregnancy, birth weight, kind and duration of labor, type of delivery, presentation, sedation and
anesthesia (if known), state of infant at birth, resuscitation required, onset of respiration, first cry.

C. Neonatal: APGAR score; color, cyanosis, pallor, jaundice, cry, twitchings, excessive mucus, paralysis, convulsions,
fever, hemorrhage, congenital abnormalities, birth injury. Difficulty in sucking, rashes, excessive weight loss, feeding
difficulties. You might discover a problem area by asking if baby went home from hospital with his mother.

D. Growth and Development:

1. Mother and Mental Development

a. First raised head, rolled over, sat alone, pulled up, walked with help, walked alone, talked (meaningful words; sentences),
DDST when appropriate.
b. Urinary continence during night; during day.

c. Control of feces.
d. Comparison of development with that of siblings and parents.
e. School grade, quality of work.

E. Nutrition

1. Breast or Formula: Type, duration, major formula changes, time of weaning, difficulties. Be specific about how much
milk or formula the baby receives.
2. Vitamin Supplements: Type, when started, amount, duration.
3. "Solid" Foods: When introduced, how taken, types.
4. Appetite: Food likes and dislikes, idiosyncrasies or allergies, reaction of child to eating. An idea of child's usual daily
intake is important.

F. Past Illnesses - A comment should first be made relative to the child's previous general health, then the specific areas
listed below should be explored.

1. Infections: Age, types, number, severity.

2. Contagious Diseases: Age, complications following measles, rubella, chickenpox, mumps, pertussis, diphtheria, scarlet
fever.
3. Past Hospitalizations: including operations, age.
4. Allergies, with specific attention to drug allergies - detail type of reaction.

5. Medications patient is currently taking.

G. Immunizations and Tests - Be familiar with departmental recommendations for immunizations. List date and type of
immunization as well as any complications or reactions.

H. Accidents and Injuries (include ingestions): Nature, severity, sequelae.

I. Behavioral History

1. Does child manifest any unusual behavior such as thumb sucking, excessive masturbation, severe and frequent temper
tantrums, negativism, etc.?
2. Sleep disturbances.
3. Phobias.
4. Pica (ingestions of substances other than food).
5. Abnormal bowel habits, ex. - stool holding.

6. Bed wetting (applicable only to child out of diapers).

V. Family History - use family tree whenever possible

A. Father and mother (age and condition of health). What sort of people do the parents characterize themselves as being?

B. Marital relationships. Little information should be sought at first interview; most information will be obtained indirectly.

C. Siblings. Age, condition of health, significant previous illnesses and problems.

D. Stillbirths, miscarriages, abortions; age at death and cause of death of immediate members of family.

E. Tuberculosis, allergy, blood dyscrasias, mental or nervous diseases, diabetes, cardiovascular diseases, kidney disease,
rheumatic fever, neoplastic diseases, congenital abnormalities, cancer, convulsive disorders, others.

F. Health of contacts.

VI. Social History

VII. Environmental History

VIII. System Review

A system review will serve several purposes. It will often bring out symptoms or signs missed in collection of data about
the present illness. It might direct the interviewer into questioning about other systems that have some indirect bearing on
the present illness (ex. - eczema in a child with asthma). Finally, it serves as a screening device for uncovering symptoms,
past or present, which were omitted in the earlier part of the interview. There is no need to repeat previously recorded
information in writing a Review of Systems.

A. Skin: Ask about rashes, hives, problems with hair, skin texture or color, etc.

B. Eyes: Have the child's eyes ever been crossed? Any foreign body or infection, glasses for any reason.

C. Ears, Nose and Throat: Frequent colds, sore throat, sneezing, stuffy nose, discharge, post-nasal drip, mouth breathing,
snoring, otitis, hearing, adenitis.

D. Teeth: Age of eruption of deciduous and permanent; number at one year; comparison with siblings.

E. Cardiorespiratory: Frequency and nature of disturbances. Dyspnea, chest pain, cough, sputum, wheeze, expectoration,
cyanosis, edema, syncope, tachycardia.

F. Gastrointestinal: Vomiting, diarrhea, constipation, type of stools, abdominal pain or discomfort, jaundice.
G. Genitourinary: Enuresis, dysuria, frequency, polyuria, pyuria, hematuria, character of stream, vaginal discharge,
menstrual history, bladder control, abnormalities of penis or testes.

H. Neuromuscular: Headache, nervousness, dizziness, tingling, convulsions, habit spasms, ataxia, muscle or joint pains,
postural deformities, exercise tolerance, gait.

I. Endocrine: Disturbances of growth, excessive fluid intake, polyphagia, goiter, thyroid disease.

J. Special senses.

K. General: Unusual weight gain or loss, fatigue, temperature sensitivity, mentality. Pattern of growth (record previous
heights and weights on appropriate graphs). Time and pattern of pubescence.
PHYSICAL EXAM

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pEDIATRIC HISTORY AND PHYSICAL EXAM

PHYSICAL EXAMINATION

Every child should receive a complete systematic examination at regular intervals. One should not restrict the examination
to those portions of the body considered to be involved on the basis of the presenting complaint.

Approaching the Child

Adequate time should be spent in becoming acquainted with the child and allowing him/her to become acquainted with the
examiner. The child should be treated as an individual whose feelings and sensibilities are well developed, and the
examiner's conduct should be appropriate to the age of the child. A friendly manner, quiet voice, and a slow and easy
approach will help to facilitate the examination.

Observation of the Patient

Although the very young child may not be able to speak, one still may receive much information from him/her by being
observant and receptive. The total evaluation of the child should include impressions obtained from the time the child first
enters until s/he leaves; it should not be based solely on the period during which the patient is on the examining table. In
general, more information is obtained by careful inspection than from any of the other methods of examination.

Sequence of Examination
Skill, tact and patience are required to gather an optimal amount of information when examining a child. There is no
routine one can use and each examination should be individualized. Ham it up and regress. Get down to the child's level
and try to gain his trust. The order of the exam should conform to the age and temperament of the child. For example,
many infants under 6 months are easily managed on the examining table, but from 8 months to 3 years you will usually have
more success substituting the mother's lap. Certain parts of the exam can sometimes be done more easily with the child in
the prone position or held against the mother. After 4 years, they are often cooperative enough for you to perform the exam
on the table again.

Wash your hands with warm water before the examination begins. You will impress your patient's mother and not begin
with an adverse reaction to cold hands in your patients. With the younger child, get to the heart, lungs and abdomen before
crying starts. Save looking at the throat and ears for last. If part of the examination is uncomfortable or painful, tell the
child in a warm, honest, but determined tone that this is necessary. Looking for animals in their ears or listening to birdies
in their chests is often another useful approach to the younger child.
If your bag of tricks is empty and you've become hoarse from singing and your lips can no longer bring forth a whistle, you
may have to turn to muscle. Various techniques are used to restrain children and experience will be your best ally in each
type of situation.

Remember that you must respect modesty in your patients, especially as they approach pubescence. Some time during the
examination, however, every part of the child must have been undressed. It usually works out best to start with those areas
which would least likely make your patient anxious and interfere with his developing confidence in you.

General Physical Examination

I. Vital Signs and Measurements

Temperature, pulse rate, and respiratory rate (TPR); blood pressure (the cuff should cover 2/3 of the upper arm), weight,
height, and head circumference. The weight should be recorded at each visit; the height should be determined at monthly
intervals during the first year, at 3-month intervals in the second year, and twice a year thereafter. The height, weight, and
circumference of the child should be compared with standard charts and the approximate percentiles recorded. Multiple
measurements at intervals are of much greater value than single ones since they give information regarding the pattern of
growth that cannot be determined by single measurements.

II. General Appearance

Does the child appear well or ill? Degree of prostration; degree of cooperation; state of comfort, nutrition, and
consciousness; abnormalities, gait, posture, and coordination; estimate of intelligence; reaction to parents, physician, and
examination; nature of cry and degree of activity, facies and facial expression.

III. Skin

Color (cyanosis, jaundice, pallor, erythema), texture, eruptions, hydration, edema, hemorrhagic manifestations, scars, dilated
vessels and direction of blood flow, hemangiomas, cafe-au-lait areas and nevi, Mongolian (blue-black) spots, pigmentation,
turgor, elasticity, and subcutaneous nodules. Striae and wrinkling may indicate rapid weight gain or loss. Sensitivity, hair
distribution and character, and desquamation.

*Practical notes:

A. Loss of turgor, especially of the calf muscles and skin over abdomen, is evidence of dehydration.
B. The soles and palms are often bluish and cold in early infancy; this is of no significance.

C. The degree of anemia cannot be determined reliably by inspection, since pallor (even in the newborn) may be normal and
not due to anemia.

D. To demonstrate pitting edema in a child it may be necessary to exert prolonged pressure.

E. A few small pigmented nevi are commonly found, particularly in older children.
F. Spider nevi occur in about 1/6 children under 5 years of age and almost ½ of older children.

G. "Mongolian spots" (large, flat black or blue-black areas) are frequently present over the lower back and buttocks; they
have no pathologic significance.

H. Cyanosis will not be evident unless at least 5 gm of reduced hemoglobin are present; therefore, it develops less easily in
an anemic child.

I. Carotenemic pigmentation is usually most prominent over the palms and soles and around the nose, and spares the
conjunctivas.

IV. Lymph Nodes

Location, size, sensitivity, mobility, consistency. One should routinely attempt to palpate suboccipital, preauricular,
anterior cervical, posterior cervical, submaxillary, sublingual, axillary, epitrochlear, and inguinal lymph nodes.

*Practical notes:

A. Enlargement of the lymph nodes occurs much more readily in children than in adults.

B. Small inguinal lymph nodes are palpable in almost all healthy young children. Small, mobile, non-tender shotty nodes
are commonly found in residue of previous infection.

V. Head

Size, shape, circumference, asymmetry, cephalhematoma, bosses, craniotabes, control, molding, bruit, fontanel (size,
tension, number, abnormally late or early closure), sutures, dilated veins, scalp, hair (texture, distribution, parasites),
face, transillumination.

*Practical notes:

A. The head is measure at its greatest circumference; this is usually at the midforehead anteriorly and around to the most
prominent portion of the occiput posteriorly. The ration of head circumference to circumference of the chest or abdomen is
usually of little value.

B. Fontanel tension is best determined with the quiet child in the sitting position.

C. Slight pulsations over the anterior fontanel may occur in normal infants.

D. Although bruits may be heard over the temporal areas in normal children, the possibility of an existing abnormality
should not be overlooked.

E. Craniotabes may be found in the normal newborn infant (especially the premature) and for the first 2-4 months.
F. A positive Macewen's sign ("cracked pot" sound when skull is purcussed with one finger) may be present normally as
long as the fontanel is open.

G. Transillumination of the skull can be performed by means of a flashlight with a sponge rubber collar so that it forms a
tight fit when held against the head.

VI. Face

Symmetry, paralysis, distance between nose and mouth, depth of nasolabial folds, bridge of nose, distribution of hair, size
of mandible, swellings, hypertelorism, Chvostek's sign, tenderness over sinuses.

VII. Eyes

Photophobia, visual acuity, muscular control, nystagmus, Mongolian slant, Brushfield spots, epicanthic folds, lacrimation,
discharge, lids, exophthalmos or enophthalmos, conjunctivas; pupillary size, shape, reaction to light and accommodation;
media (corneal opacities, cataracts), fundi, visual fields (in older children). At 2-4 weeks an infant will follow light. By 3-4
months, coordinated eye movements should be seen.

*Practical notes:

A. The newborn infant will usually open his eyes if he/she is placed in the prone position, supported with one hand on the
abdomen, and lifted over the examiner's head.

B. Not infrequently, one pupil is normally larger than the other. This sometimes occurs only in bright or in subdued light.

C. Examination of the fundi should be part of every complete physical examination, regardless of the age of the child;
dilatation of pupils may be necessary for adequate visualization.

D. A mild degree of strabismus may be present during the first 6 months of life but should be considered abnormal after that
time.

E. To test for strabismus in the very young or uncooperative child, note where a distant source of light is reflected from the
surface of the eyes; the reflection should be present on corresponding portions of the two eyes.

F. Small areas of capillary dilatation are commonly seen on the eyelids of normal newborn infants.

G. Most infants produce visible tears during the first few days of life.

VIII. Nose

Exterior, shape, mucosa, patency, discharge, bleeding, pressure over sinuses, flaring of nostrils, septum.

At birth the maxillary antrum and anterior and posterior ethmoid cells are present. At 2-4 years pneumatization of the
frontal sinus takes place but is rarely a site of infection until the 6th - 10th year. Though the sphenoid sinus is present at
birth, it does not assume clinical significance until the 5th to 8th year.

IX. Mouth

Lips (thinness, downturning, fissures, color, cleft), teeth (number, position, caries, mottling, discoloration, notching,
malocclusion or malalignment), mucosa (color, redness of Stensen's duct, enanthems, Bohn's nodules, Epstein's pearls),
gum, palate, tongue, uvula, mouth breathing, geographic tongue (usually normal).

X. Throat

Tonsils (size, inflammation, exudate, crypts, inflammation of the anterior pillars), mucosa, hypertrophic lymphoid tissue,
postnasal drip, epiglottis, voice (hoarseness, stridor, grunting, type of cry, speech). The number and condition of the teeth
should be recorded. (A child should have 20 teeth by age 2½ years. When the teeth begin to erupt is quite variable but most
infants have their two lower central incisors by 8-10 months.

A. Before examining a child's throat it is advisable to examine his mouth first. Permit the child to handle the tongue blade,
nasal speculum and flashlight so that he/she can overcome his fear of the instruments. Then ask the child to stick out his
tongue and say "Ah" louder and louder. In some cases this may allow an adequate examination. In others, if the child is
cooperative enough, he/she may be asked to "pant like a puppy;" while he/she is doing this, the tongue blade is applied
firmly to the rear of the tongue. Gagging need not be elicited in order to obtain a satisfactory examination. In still other
cases, it may be expedient to examine one side of the tongue at a time, pushing the base of the tongue to one side and then to
the other. This may be less unpleasant and is less apt to cause gagging.

B. Young children may have to be restrained to obtain an adequate examination of the throat. Eliciting a gag reflex may be
necessary if the oral pharynx is to be adequately seen.

C. The small child's head may be restrained satisfactorily by having the mother place her hands at the level of the child's
elbows while the arms are held firmly against the sides of his head.

D. If the child can sit up, the mother is asked to hold him erect in her lap with his back against her chest. She then holds his
left hand in her left hand and his right hand in her right hand, and places them against the child's groin or lower thighs to
prevent him from slipping down from her lap. If the throat is to be examined in natural light, the mother faces the light. If
artificial light and a head mirror are used, the mother sits with her back to the light. In either case, the physician uses one
hand to hold the head in position and the other to manipulate the tongue blade.

E. Young children seldom complain of sore throat even in the presence of significant infection of the pharynx and tonsils.

XI. Ears

Pinnas (position, size), canals, tympanic membranes (landmarks, mobility, perforation, inflammation, discharge), mastoid
tenderness and swelling, hearing (including hearing screen).

*Practical notes:
A. A test for hearing is an important part of the physical examination of every infant.

B. The ears of all sick children should be examined.

C. Before actually examining the ears, it is often helpful to place the speculum just within the canal, remove it and place it
lightly in the other ear, remove it again, and proceed in this way from one ear to the other, gradually going farther and
farther, until satisfactory examination is completed.

D. In examining the ear, as large a speculum as possible should be used and should be inserted no farther than necessary,
both to avoid discomfort and to avoid pushing wax in front of the speculum so that it obscures the field. The otoscope
should be held balanced in the hand by holding the handle at the end nearest the speculum. One finger should rest against
the head to prevent injury resulting from sudden movement by the child.

E. The child may be restrained most easily if he/she is lying on his abdomen.

F. Low-set ears are present in a number of congenital syndromes, including several that are associated with mental
retardation. The ears may be considered low-set if they are below a line drawn from the lateral angle of the eye and the
external occipital protuberance.

G. Congenital anomalies of the urinary tract are frequently associated with abnormalities of the pinnas.

H. To examine the ears of an infant it is usually necessary to pull the auricle backward and downward; in the older child the
external ear is pulled backward and upward.

XII. Neck

Position (torticollis, opisthotonos, inability to support head, mobility), swelling, thyroid (size, contour, bruit, isthmus,
nodules, tenderness), lymph nodes, veins, position of trachea, sternocleidomastoid (swelling, shortening), webbing, edema,
auscultation, movement, tonic neck reflex.

*Practical notes:

In the older child, the size and shape of the thyroid gland may be more clearly defined if the gland is palpated from behind.

XIII. Thorax

Shape and symmetry, veins, retractions and pulsations, beading, Harrison's groove, flaring of ribs, pigeon breast, funnel
shape, size and position of nipples, breasts, length of sternum, intercostal and substernal retraction, asymmetry, scapulas,
clavicles.

*Practical notes:

At puberty, in normal children, one breast usually begins to develop before the other. In both sexes tenderness of the breasts
is relatively common. Gynecomastia is not uncommon in the male.
XIV. Lungs

Type of breathing, dyspnea, prolongation of expiration, cough, expansion, fremitus, flatness or dullness to percussion,
resonance, breath and voice sounds, rales, wheezing.

*Practical notes:

A. Breath sounds in infants and children normally are more intense and more bronchial, and expiration is more prolonged,
than in adults.

B. Most of the young child's respiratory movement is produced by abdominal movement; there is very little intercostal
motion.

C. If one places the stethoscope over the mouth and subtracts the sounds heard by this route from the sounds heard through
the chest wall, the difference usually represents the amount produced intrathoracically.

XV. Heart

Location and intensity of apex beat, precordial bulging, pulsation of vessels, thrills, size, shape, auscultation (rate, rhythm,
force, quality of sounds - compare with pulse as to rate and rhythm; friction rub-variation with pressure), murmurs (location,
position in cycle, intensity, pitch, effect of change of position, transmission, effect of exercise).

*Practical notes:

A. Many children normally have sinus arrhythmia. The child should be asked to take a deep breath to determine its effect
on the rhythm.

B. Extrasystoles are not uncommon in childhood.

C. The heart should be examined with the child recumbent.

XVI. Abdomen

Size and contour, visible peristalsis, respiratory movements, veins (distension, direction of flow), umbilicus, hernia,
musculature, tenderness and rigidity, tympany, shifting dullness, tenderness, rebound tenderness, pulsation, palpable organs
or masses (size, shape, position, mobility), fluid wave, reflexes, femoral pulsations, bowel sounds. If the liver is palpable
below the right costal margin, its total span must be recorded. A deep abdomen palpation must be done on every child.

*Practical notes:

A. The abdomen may be examined while the child is lying prone in the mother's lap or held over her shoulder, or seated on
the examining table with his back to the doctor. These positions may be particularly helpful where tenderness, rigidity, or a
mass must be palpated. In the infant the examination may be aided by having the child suck at a "sugar tip" or nurse at a
bottle.
B. Light palpation, especially for the spleen, often will give more information than deep.

C. Umbilical hernias are common during the first 2 years of life. They usually disappear spontaneously.

XVII. Male Genitalia

Circumcision, meatal opening, hypospadias, phimosis, adherent foreskin, size of testes, cryptorchidism, scrotum, hydrocele,
hernia, pubertal changes.

*Practical notes:

A. In examining a suspected case of cryptorchidism, palpation for the testicles should be done before the child has fully
undressed or become chilled or had the cremasteric reflex stimulated. In some cases, examination while the child is in a hot
bath may be helpful. The boy should also be examined while sitting in a chair holding his knees with his heels on the seat;
the increased intra-abdominal pressure may push the testes into the scrotum.

B. To examine for cryptorchidism, one should start above the inguinal canal and work downward to prevent pushing the
testes up into the canal or abdomen.

C. In the obese body, the penis may be so obscured by as to appear abnormally small. If this fat is pushed back, a penis of
normal size is usually found.

XVIII. Female Genitalia

Vagina (imperforate, discharge, adhesions), hypertrophy of clitoris, pubertal changes.

*Practical note:

Digital or speculum examination is rarely done until after puberty.

XIX. Rectum and Anus

Irritation, fissures, prolapse, imperforate anus. The rectal examination should be performed with the little finger (inserted
slowly). Note muscle tone, character of stool, masses, tenderness, sensation. Examine stool on glove finger (gross,
microscopic, culture, guaiac), as indicated.

XX. Extremities

A. General: Deformity, hemiatrophy, bowlegs (common in infancy), knock-knees (common after age 2), paralysis, edema,
coldness, posture, gait, stance, asymmetry.

B. Joints: Swelling, redness, pain, limitation, tenderness, motion, rheumatic nodules, carrying angle of elbows, tibial torsion.

C. Hands and feet: Extra digits, clubbing, simian lines, curvature of little finger, deformity of nails, splinter hemorrhages,
flat feet (feet commonly appear flat during first 2 years), abnormalities of feet, dermatoglyphics, width of thumbs and big
toes, syndactyly, length of various segments, dimpling of dorsa, temperature.

D. Peripheral Vessels: Presence, absence or diminution of arterial pulses.

XXI. Spine and Back

Posture, curvatures, rigidity, webbed neck, spina bifida, pilonidal dimple or cyst, tufts of hair, mobility, Mongolian spots,
tenderness over spine, pelvis or kidneys.

XXII. Neurologic Examination

A. Cerebral Function: General behavior, level of consciousness, intelligence, emotional status, memory, orientation,
illusions, hallucinations, cortical sensory interpretation, cortical motor integration, ability to understand and communicate,
auditory-verbal and visual-verbal comprehension, recognition of visual object, speech, ability to write, performance of
skilled motor acts.

B. Cranial Nerves:

1. I (olfactory) - Identify odors; disorders of smell

2. II (optic) - Visual acuity, visual fields, ophthalmoscopic examination, retina.

3. III (oculomotor), IV (trochlear), and VI (abducens) - Ocular movements, ptosis, dilatation of pupil, nystagmus, pupillary
accommodation, and pupillary light reflexes.

4. V (trigeminal) - Sensation of face, corneal reflex, masseter and temporal muscles, maxillary reflex (jaw jerk).

5. VII (facial) - Wrinkle forehead, frown, smile, raise eyebrows, asymmetry of face, strength of eyelid muscles, taste on
anterior portio of tongue.

6. VIII (acoustic) -
a. Cochlear portion - Hearing, lateralization, air and bone conduction, tinnitus.
b. Vestibular - Caloric tests.
7. IX (glossopharyngeal), X (vagus) - Pharyngeal gag reflex, ability to swallow and speak clearly; sensation of mucosa of
pharynx, soft palate, and tonsils; movement of pharynx, larynx, and soft palate; autonomic functions.

8. XI (accessory) - Strength of trapezius and sternocleidomastoid muscles.

9. XII (hypoglossal) - Protrusion of tongue, tremor, strength of tongue.

C. Cerebellar Function: Finger to nose, finger to examiner's finger, rapidly alternating pronation and supination of hands;
ability to run heel down other shin and to make a requested motion with foot; ability to stand with eyes closed; walk; heel to
toe walk; tremor; ataxia; posture; arm swing when walking; nystagmus; abnormalities of muscle tone or speech.

D. Motor System: Muscle size, consistency, and tone; muscle contours and outlines; muscle strength; myotonic contraction;
slow relaxation; symmetry or posture; fasciculations; tremor; resistance to passive movement; involuntary movement.

E. Sensory System: Hearing, vision, light touch, pain, position, vibration.

F. Reflexes:

1. Deep reflexes - Biceps, brachioradialis, triceps, patellar, Achilles; rapidity and strength of contraction and relaxation.

2. Superficial reflexes - Abdominals, cremasteric, plantar, gluteal.

3. Pathologic reflexes - Babinski, Chaddock, Oppenheim, Gordon.

G. Newborn Neurological Examination

*Practical Points:

Observe the normal flexion of the term infant in contrast to the nonflexed, even flaccid appearance of the normal resting
premature. The shape of the premature skull is usually dolichocephalic (long and narrow). Elicit the normal reflexes of
grasping (hand and foot), sucking, rooting, Moro and automatic walking. Palpate the head to identify the anterior and
posterior fontanelles as well as the sagittal, coronal, metopic and lambdoid sutures.

NORMAL NEWBORN: HISTORY AND PHYSICAL EXAM OUTLINE

Comments to our site editor.

UA College of Medicine : Arizona Health Sciences Center : The University of Arizona

The University of Arizona Department of Pediatrics

1501 N. Campbell Avenue , PO Box 245073
Tucson, Arizona 85724
Phone: (520) 626-6053

All contents ©2009 Arizona Board of Regents. All rights reserved.

The University of Arizona is an EEO/AA - M/W/D/V Employer.

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NORMAL NEWBORN: HISTORY AND PHYSICAL

EXAM OUTLINE
Infant:

Birth weight, gestational age, intrauterine growth (AGA, SGA, LGA), race, sex, date and time of birth.

Maternal:

Age; Gravida , Para , SAB , TAB , SB , LC ; blood type, VDRL/RPR (date and results), race, EDC.
Previous complications of pregnancy, labor, delivery. Type of contraception used, if any. Was present pregnancy planned?

Pregnancy:

Location of prenatal care and number of visits. Complications of pregnancy: Special test, ultrasound exams, stress tests.
Medications - drug, dose, route, length of therapy, indication, when used during pregnancy.

Labor and Delivery:

• Labor spontaneous or induced?

• Complications of labor
• Fetal monitoring? Fetal distress?
• Rupture of membranes: artificial or spontaneous, hours before delivery, character of fluid.
• Medications - including analgesia and anesthesia: drug, dose, route, time prior to delivery
 • Duration - Stage I, Stage II, Stage III
• Vaginal - or C-section delivery
• Fetal presentation and position
• Forceps used? If so, state type and indication
• Apgars 1 min/5 min (Specify points lost at each)
• Resuscitation: none; bulb suction; free flowing oxygen; bag and mask; intubation, drugs used (dose and route)

Transitional Nursery:

• VS on admission (including BP and temperature)

• Hematocrit
• Dextrostic
• Problems: cyanosis, respiratory distress, etc.
• Estimate of gestational age by Dubowitz - physical score, neuromuscular score

Family:
Relationship of neonate's mother and father (married, divorced, cohabiting, live apart, no contact maintained, etc.)

Mother: amount of education, and is she employed outside of the home?

Father: age, amount of education, occupation

Any illnesses or other problems in household members?

Any significant illnesses (physical, mental, growth failure) in other members of father's or mother's family? If so,
what?

Is there any disorder(s) in particular that mother worries her child might develop?

Environment:

o Type of housing (trailer, apartment, etc.)

o Number of bedrooms; running water, bath; explain problems.
o Is adequate heating or cooling a problem? If yes, explain.
o Is there a crib or adequate substitute for the baby?
o Do any of the children sleep in the same bed or same room as their parents?
o Are there adults other than the parents sleeping or living in the house?
o Approximate level of income. Are there a lot of debts?
o Will the baby be an added financial stress?
o Any previous contact with social agencies? If so, which ones and opinions about the reasons for using the
resources.
o Any relatives or friends in town? Type of support systems they provide?

Mother-Child Relationship:
Mother's affect; attitude toward the child; knowledge of child care.

PHYSICAL EXAMINATION
Vital Signs: T ___ C Weight ___ gm (% of Colorado Intrauterine Growth Curve)
P ___ Length ___cm (% of Colorado Intrauterine Growth Curve)
R ___ Head Circumference ___cm (% " " " )
BP ___ Chest Circumference ___cm (% " " " )

General: Describe resting posture, activity, gross abnormality, color (pink, cyanotic/acrocyanotic, pale mottled)

Skin: Texture, lanugo, vernix, meconium staining, icterus, hemangioma, nevi, rash, excoriation, petechiae, bruises.

Head: General shape, molding, caput, cephalohematome, sutures (over-riding, separated), craniotabes. Fontanel -
anterior, posterior (presence, size, flat/full). Texture of hair.

Eyes: Edema, conjunctival or anterior chamber hemorrhage, discharge. Size of eye; cornea, iris normal? Lens
clear? Red reflex present? Retina visualized? PERL?

Nose: Internal and external nares patent? Septum midline? Drainage present?

Ears: Cartilaginous development of the ear lobe, position of ears, shape of auricle (normal/abnormal), preauricular
sinus or skin tags. External auditory canal patent.

Mouth: Palate (intact, narrow or high arched), Epstein's pearls, mucosal cysts, teeth, tongue (size, position),
frenulum, uvula.

Chin: Micrognathia.

Neck: Trachea position. Masses (thyroid, sternocleidomastoid, etc.), cysts, sinus tracts, movement, nodes.

Chest: Symmetry. Breast buds (measure diameter in mm). Clavicles intact? Supernumerary nipples? Axillary
adenopathy.

Lungs: Retractions, flaring, grunting, tachypnea, auscultation (rales, rhonchi, wheezes)

CVS: PMI, rhythm, rate (tachycardia, bradycardia)

S1, S2 (amplitude equal? S2 split?)
Murmur (quality, intensity, duration, relation to cardiac cycle, radiation, location of maximum intensity)
Peripheral pulses - femoral, brachial, radial (amplitude, equality, simultaneous)
Peripheral perfusion (capillary filling time)

Abdomen: Shape, muscle tone, number of umbilical vessels, hernia/diastasis. If palpable, note size and consistency
of liver, spleen, kidney, or other masses. Inguinal adenopathy?

Genitourinary:
Female- size of clitoris and labia, masses in labia, hymenal tags, discharges, abnormalities in voiding.

Male - urethral meatus patency and position, chordee, testicular descent and scrotal development (i.e., rugae only on
inferior aspect, or surface completely covered with rugae and pendulous in appearance). Hernia or hydrocele,
abnormalities in voiding.

Anus: Patency, anal wink, abnormal stooling.

Extremities: Symmetry, ROM, abduction of hips, position of hands and feet.

Number, shape, length of digits, length of nails, Palmar creases normal? Subcutaneous tissue normal?

Spine: Sinus tracts, sacral dimple, scolioses

Neurologic:
Tone: active
Dubowitz (Ballard form); also ventral supervision
Head lag; leg and trunk straightening passive
Cry: character, intensity, frequency
Behavior: alertness, wakefulness, irritability, consoleability, cuddliness
Reflexes:
Suck Grasp (palmer/plantar) Pacing Cross extension
Root Tonic neck Stepping Glabellar tap
Moro Galant Rotation Palmar-mentum

DTRs (knee, angle, plantar, triceps, biceps) draw figure

Tremor, clonus present?
Paralysis: facial brachial

Estimated Gestational Age:

___ EDC ___ Dubowitz __ _ Obstetrical Prenatal Assessment

PROBLEM LIST

1. Health Care Maintenance (HCM)

2. Per history and physical (list plan with each problem)

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UA College of Medicine : Arizona Health Sciences Center : The University of Arizona

The University of Arizona Department of Pediatrics

1501 N. Campbell Avenue , PO Box 245073
Tucson, Arizona 85724
Phone: (520) 626-6053

All contents ©2009 Arizona Board of Regents. All rights reserved.

The University of Arizona is an EEO/AA - M/W/D/V Employer.